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FAQs on Pre-existing Disease Coverage in Health Plans

17 May 2022, 12:34 PM

Pre-existing illnesses are defined as those illnesses or medical conditions which an insured already suffers from at the time of buying a health insurance policy. 

Since these medical conditions are known and have been diagnosed, insurance companies do not cover them and their complications in the initial few years of the policy. There is a waiting period for pre-existing illnesses and when the waiting period is over, the illnesses get covered under the plan. 

Coverage of pre-existing illnesses in health insurance plans is, more or less, the same across insurance companies. However, many times you might be confused about the coverage conditions on pre-existing illnesses. 

Most Commonly Asked Questions About Pre-existing Coverage in Health Plans 

   1. How do pre-existing conditions affect a health insurance plan?

In the case of a pre-existing medical condition, the possibility of a claim being made rises. This automatically makes health insurance companies reluctant to cover such conditions. They, therefore, impose a waiting period for pre-existing conditions and allow coverage for such conditions after the waiting period is over. Moreover, depending on the severity of the illness, a higher premium amount, a restriction in coverage, or both might be imposed based on company policies. 

  2. What is the waiting period for pre-existing diseases? 

Any illness that is diagnosed before the policy starts is considered to be a pre-existing disease. Most insurance companies have an initial period during which the pre-existing disease coverage is not provided. This is called the waiting period for pre-existing diseases only. This tenure usually ranges from 24 months to 48 months, depending on the policy. Thus, the waiting period is the period during which coverage for pre-existing conditions is not allowed.

  3. What is the best way to avoid the waiting period?

As mentioned above, every pre-existing medical condition would be subject to a waiting period. This implies that any complications arising as a result of these diseases shall not be covered during this period. In order to avoid facing the risk of a waiting period, it is in the best interests of the applicant to choose the right policy for themselves at a young age when they are free from most ailments. As you grow older, the chances of contracting diseases increases and you are not covered for pre-existing conditions of the waiting period. When you buy health insurance at a younger age, you can wait out the waiting period as you are healthy and then avail yourself comprehensive coverage when illnesses do strike.

  4. How does one buy health insurance plans for parents with pre-existing medical conditions?

It is a daunting task to get a health insurance plan for your parents, especially if they already have a pre-existing medical condition. However, since health insurance for parents is a must, you should look for senior citizen health plans which have a low waiting period for pre-existing illnesses. There might be pre-entrance health check-ups and the premiums might be higher for existing illnesses but you can get your parents covered even if they have pre-existing conditions. 

  5. Are all ailments considered pre-existing conditions?

The above question can be answered in one word – ‘No’. Not all ailments or visits to the doctor are categorised as a sign of pre-existing medical conditions. Insurers only take into account those medical ailments or conditions that have a long term effect on a person’s health or well-being. Minor ailments or side effects like cough, cold, headaches, fever, etc. do not determine a person’s health and are not considered as pre-existing conditions.

   6. What is pre-existing condition exclusion? 

The pre-existing condition exclusion is a clause that the insurance provider can put in case of chronic or adverse cases of pre-existing illnesses. For instance, if the insured is a severe diabetic, insurance companies can exclude coverage for diabetes-related illnesses altogether. So, in the event of a medical emergency occurring due to an excluded pre-existing medical condition, claims would not be paid.

  7. What is pre pre-existing condition waiver? 

Under some health insurance plans, pre-existing illness waiver benefit is allowed as an optional cover. Under this benefit, the right of the insurance provider to exclude pre-existing medical conditions from coverage during the waiting period is waived off. You can, thus, enjoy coverage for pre-existing medical conditions from the first day of the policy. 

This waiver benefit is available with a handful of health plans and comes at an additional premium. Moreover, this benefit is available for individuals who have mild cases of pre-existing illnesses. In severe cases, this benefit might not be allowed. 

Some insurers which offer Day 1 coverage such as Star Health, Aditya Birla Health Insurance and HDFC Ergo. Some of the plans are:

  1. Aditya Birla Activ Health Essential - Diabetes,
  2. Aditya Birla Activ Health Platinum Enhanced - Diabetes,
  3. Star Cardiac Care-Gold
  4. Star Health Diabetes Safe Plan A and
  5. HDFC Ergo Health Energy Gold

  8. How does portability affect the pre-existing waiting period?

The Insurance Regulatory and Development Authority (IRDA) has made provisions for the portability of all health insurance policies. In case someone with a pre-existing medical condition decides to shift from one insurance provider to another, they can do so without having to go through the waiting period all over again. On porting the plan you get credit for the waiting period already elapsed in the last policy. The waiting period of the new policy is reduced by the tenure of the old policy so that you don’t have to face a double waiting period.

  9. What would happen to the pre-existing waiting period if I increase the sum insured?

If the sum insured is enhanced, the waiting period would apply again on the increased part of the sum insured. 

For instance, say you buy a health plan for INR 5 lakhs with a waiting period of 3 years. After 2 years you increase the sum insured to INR 10 lakhs. In this case, on the first INR 5 lakhs a waiting period of 1 year would be left. However, for the enhanced sum insured of INR 5 lakhs, a fresh waiting period of 3 years would apply again. 

So, basically after 1 year, you can health insurance claim INR 5 lakhs for your pre-existing disease. After 3 years, you can claim the entire amount of INR 10 lakhs for your pre-existing disease.

It means that if the insured files a claim in the 4th year of policy to get treatment for pre-existing disease, then the claim amount by the insurance company would be only up to INR 5 lakhs. However, if the insured files the claim for a pre-existing disease treatment after the completion of the 5th year, would be eligible for a total claim amount of up to INR 10 lakhs.   

  10. What would happen if I do not disclose my pre-existing illness when buying health insurance?

Insurance policies are contracts of utmost good faith wherein you are required to disclose all important information to the insurance company when buying the plan. You must not hide your pre-existing condition when buying the policy. This is because, if there is a claim for the pre-existing condition, the insurer would reject the claim. This would hold the policy void because of the non-disclosure of material facts. Thus, you should always inform the insurance company of any and all pre-existing conditions that you have when buying the plan.

So, understand the meaning and implication of pre-existing illnesses on your health insurance plan before you buy one. Pre-existing illnesses are usually covered in health plans after the waiting period. So, if you have any pre-existing condition, inform the insurance company when buying the policy, wait out the waiting period and then enjoy comprehensive coverage under the health insurance plan.

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